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The WellBeing of the Paramedic

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Title: The WellBeing of the Paramedic


1
The Well-Being of the Paramedic
I wish we had a one-man stretcher!
2
Wellness Components
  • Physical well-being
  • and
  • Mental and emotional health
  • The physical as well as mental emotional health
    are critical to the EMS providers health and
    safety in order to function during stressful times

3
Physical Well-Being
  • Several factors play a major role
    in maintaining physical health
  • Good nutrition
  • Physical fitness
  • Adequate sleep
  • Disease prevention
  • Injury prevention

4
Assessing Your Risk Factors
  • Gives valuable insight into your personal
    well-being
  • Assess for
  • pertinent family history
  • symptoms/conditions currently present
  • daily levels of exercise activity/commitment
  • diet body mass index
  • lifestyle habits (smoking, stress, activity,
    addictions)

5
Nutrition
  • Nutrients
  • Foods that contain elements necessary for body
    function
  • Six categories
  • Carbohydrates
  • Fats
  • Proteins
  • Vitamins
  • Minerals
  • Water

6
Carbohydrates
  • Composed of carbon, hydrogen,
    and oxygen
  • Primarily are obtained from
    plant foods
  • Lactose (milk sugar) only important
  • source of animal carbohydrate
  • Plants store carbohydrates as starch
  • Cooking makes starches easier to digest
  • Generally healthy intake lt300 grams/day

7
Fats Fatty Acids
  • Fats in food are mixtures of three types of fatty
    acids
  • ?Saturated fat - primarily found in meat dairy
  • raises cholesterol levels should be avoided
  • ?Polyunsaturated - found in safflower, sunflower,
    corn soybean, cottonseed oils some fish
  • helps body rid self of newly formed cholesterol

8
Fats Fatty Acids
  • ?Monounsaturated fats - liquid vegetable oils
    such as canola and olive
  • these may decrease cholesterol levels
  • The 3 types of fats differ in chemical makeup and
    in the types of foods in which they appear
  • Daily fat intake
  • total fats limited to 65 grams/day
  • saturated fats limited to 20 grams/day

9
Cholesterol
  • Present in all foods of animal origin
  • Heavily concentrated in fat and in poultry skin
  • White, waxy substance found in every cell
  • Needed by the body for normal functioning
  • Manufactured in liver and is
    carried through bloodstream
  • High blood cholesterol levels
    increase risk of heart disease and
  • stroke (healthy level is lt200 borderline
  • high is 200-239 unhealthy is gt240)

10
Cholesterol
  • HDL (average normal men - 45 women - 55)
  • good (healthy) cholesterol
  • helps carry LDL away from arteries
  • LDL (optimal level is lt100)
  • bad cholesterol
  • deposits on artery walls
  • Triglycerides (normal is lt150)
  • much of the bodys fat is stored in the form of
    triglycerides for later use as energy

11
Proteins
  • Composed of hydrogen, oxygen, carbon, and
    nitrogen
  • Most also contain sulfur and phosphorus
  • Essential to building body tissue during growth,
    maintenance, and repair
  • When digested, breaks down into
    amino acids
  • Classified as either essential
    or nonessential
  • Daily intake adequate at
  • 50 grams/day

12
Amino Acids
  • Essential amino acids
  • Absolutely necessary for body growth and cellular
    life
  • Must be obtained in food since they are not
    produced in body
  • Nonessential amino acids
  • Can be manufactured in the body

13
Proteins/Amino Acids
  • Proteins that contain all essential amino acids
    are complete proteins
  • Meats and dairy products
  • Proteins that are missing one or more essential
    amino acids are incomplete proteins
  • Grains and vegetables
  • Proteins can be used
    as
    a source of energy

14
Vitamins
  • Organic substances present in minute amounts in
    foods
  • Must be obtained in food or through vitamin
    supplements
  • Essential for metabolism
  • Cannot be produced in adequate
    amounts by the body
  • Vitamins classified as
  • Water-soluble
  • Fat-soluble

15
Water-Soluble Vitamins
  • Eight water-soluble vitamins in vitamin C and B
    complexes
  • Water-soluble vitamins
    cannot be stored in the body
  • Must be provided
    by daily diet

16
Fat-Soluble Vitamins
  • Vitamins A, D, E, and K
  • Can be stored in the body
  • Therefore, daily dietary intake of these vitamins
    not required

17
Minerals
  • Inorganic elements that play an essential role in
    biochemical reactions in the body
  • Include calcium, chromium, iron, magnesium,
    potassium, selenium, sodium, and zinc
  • Like vitamins, minerals
    are obtained through
    the diet

18
Water
  • Most important nutrient because cellular function
    depends on a fluid environment
  • Composes 50 to 60 of total body weight
  • Infants have the greatest percentage
    of body
    water older adults
    have the least
  • Obtained through consumption
    of liquids and fresh fruits
    and
    vegetables
  • Also is produced when food is
    oxidized during digestion
  • Basic rule for consumption
  • 21/2 - 31/2 liters of fluid/day

19
Food Groups
  • Food Pyramid- rough guideline periodic revisions
  • 5major food groups
  • Dairy products
  • 2-3 servings/day
  • Meat, fish, poultry
  • 2-3 servings/day
  • Vegetables
  • 3-5 servings/day
  • Fruits
  • 2-4 servings/day
  • Grains
  • 6-11 servings /day

20
Food Labels
  • Check serving size listed to avoid
    misinterpreting information
  • Reading labels helps consumer choose food wisely

21
Principles of Weight Control
  • Ideal weight controversial
  • Should be used only as a guide
  • People who are overweight tend
    to be at greater risk for developing
  • High blood pressure
  • Diabetes mellitus
  • Heart disease
  • Some cancers
  • Other illnesses

22
Ideal Body Weight
  • Common measurement of obesity is based on Body
    Mass Index (BMI)
  • BMI calculation
  • divide your weight in pounds by height in inches
  • divide that number again by height in inches
  • multiply the answer in step 2 by 703
  • BMI implications
  • 18.5 - 25 ideal body weight
  • 25 - 27 potential health risk
  • over 30 significant health risk

23
Principles of Weight Control
  • Eat right balance of foods in moderation
  • Limit fat consumption to no
    more than 65 grams of fat
    per day in a 2000
    calorie diet
  • Exercise regularly
  • generally acceptable is
  • a workout three to
  • four times per week for a minimum
  • of 30 minutes per exercise day

24
Principles of Weight Control
  • Tips to change behavior
  • Set realistic goals
  • Make a commitment to change
  • Keep to your exercise schedule
  • Make healthier food choices
  • Analyze progress

25
Physical Fitness
  • A condition that helps one look, feel, and do his
    or her best
  • Physical fitness is individual
  • Varies from person to person
  • Influenced by
  • Age
  • Gender
  • Heredity
  • Personal habits
  • Exercise
  • Eating habits

26
Benefits of Physical Fitness
  • Decrease in resting heart rate and blood pressure
  • less work load greater efficiency of body
    function
  • Increase in oxygen carrying capacity
  • Enhanced quality of life
  • Increase in muscle mass
    and metabolism
  • Increased resistance to injury
  • Improved personal appearance
    and self image
  • Maintenance of motor skills throughout
  • life

27
Cardiovascular Endurance
  • Fitness assessment
  • Heart rate target zone
  • 220 minus your age in years
  • and then multiply by 60-80
  • example
  • 220-25195
  • 195 x 0.6 117 beats/minute
  • 195 x 0.8 156 beats/minute
  • target heart rate is between
  • 117 and 156 beats per minute
  • during exercise

28
Muscular Strength
  • Strength endurance assessment
  • Principles of training
  • Isometric versus isotonic
  • isometric - no movement of joint
  • isotonic - joint moved through range of motion
  • Resistance
  • amount of weight moved or
  • lifted during isotonics
  • Sets - number of times exercise repeated
  • Frequency - minimal number of workouts needed for
    positive effect

29
Muscular Flexibility
  • Flexibility assessment
  • Principles of muscular flexibility
  • Intensity of exercise
  • Repetitions
  • Frequency
  • Prevention and
    rehabilitation of low back pain

30
Being a couch potato can be hazardous to your
health.
31
Importance of Sleep
  • Sleep deprivation leads to exhaustion
  • resistance to all stressors declines
  • increased susceptibility to physical
    psychological ailments
  • Disruption of circadian timing system
  • Circadian (Latin for about a day) rhythm -
    biological cycles that occur about every 24 hours
  • Includes hormonal body temp
  • changes, appetite sleepiness
  • cycles, other body functions

32
Disease Prevention
  • Regular check ups with your physician is
    essential to maintaining good health

33
Cardiovascular Disease
  • Components with impact on preventing heart
    disease
  • Cardiovascular endurance
  • Blood pressure monitoring
  • Body composition
  • Total cholesterol/ HDL ratio
  • Triglyceride levels
  • Estrogen use
  • Stress responses
  • Periodic risk assessment

34
Cigarette Smoking
  • Health ramifications
  • negative effects on cardiovascular system
  • increased incidence of lung cancer
  • Why people smoke
  • Peer pressure
  • Relief of stress
  • Weight control
  • Addictive properties of nicotine
  • Smoking cessation resources available

35
Cancer
  • The term cancer encompasses more than 100
    diseases affecting nearly every part of the body
  • All are potentially life-threatening
  • Fundamental cause of all cancer is a change or
    mutation in the nucleus of a cell
  • Most common cancers are linked to one of three
    environmental risk factors
  • Smoking
  • Sunlight
  • Diet

36
Steps in Cancer Prevention
  • Eliminating smoking
  • Making dietary changes
  • Minimizing sun exposure using sun screen
  • Regular physical examinations
  • Watching for the warning
    signs
  • Periodic risk assessment

37
Cancer Warning Signs(CAUTION)
  • Change in bowel or bladder habits
  • A sore throat that does not heal
  • Unusual bleeding or discharge
  • Thickening or lump in the breast or elsewhere
  • Indigestion or difficulty swallowing
  • Obvious change in a wart or mole
  • Nagging cough or hoarseness
  • Source The
    American Cancer Society

38
Infectious Disease
  • Hygiene - hand washing (20 seconds minimum) most
    effective tool to helping to keep you healthy
  • Using engineering and work practice controls
  • Reporting exposure promptly and doing follow-up
    recommended
  • Periodic risk assessment

39
Injury Prevention
  • Job-related injuries can be minimized by being
    knowledgeable about
  • Body mechanics during lifting and moving
  • Being alert for hostile environments
  • Prioritizing personal
    safety during rescue situations
  • Practicing safe vehicle
    operations
  • Using safety equipment
    and supplies

40
Body Mechanics During Lifting and Moving
  • Only move a victim you can safely handle get
    additional help if needed
  • Look where youre walking or crawling
  • Move forward rather than backward
    when possible
  • Take short steps, if walking
  • Bend at hips and knees
  • Lift with legs, not back
  • Keep load close to the body
  • Keep patients body in-line when moving

41
Hostile Environments
  • Carefully evaluate scene for safety concerns
  • Do not enter scene until it is safe
  • Coordinate all activities with law enforcement
    personnel
  • Follow protocols for establishing
    Medical Incident Command
  • Plan an entrance and escape
  • route(s)
  • Above all else, stay alert
    and be prepared for
    the
  • unexpected

42
Mental and Emotional Health
  • Substance misuse/abuse control
  • Anxiety and stress
  • Personal time/meditation/
    contemplation
  • Family, peer, community
    connections
  • Freedom from prejudice

43
Warning Signs of Addiction and Addictive Behavior
  • Using a substance to relieve tension
  • Using an increasing amount of the substance
  • Lying about using the substance
  • Experiencing guilt about using the substance
  • Avoiding discussion about using
    the substance
  • Interference with daily
    activities due to substance abuse

44
Substance Abuse Management
  • Methods used to manage substance abuse depend on
    the type of substance being misused
  • Substance misuse/abuse control may include a
    combination of professional counseling,
    physician-controlled medication therapy, and
    support programs

45
Anxiety and Stress
  • Stress results from the interaction of events
    (environmental stimuli) and the adjustive
    capabilities of the individual
  • Usually seen as generating
    negative affect (fear, depression,
    guilt, etc.)
  • Stress also experienced
  • with positive events

46
Anxiety and Stress
  • Anxiety
  • Uneasiness or dread about future uncertainties
  • Eustress
  • Good stress
  • Response to positive stimuli
  • Distress
  • Bad stress
  • A negative response to an
    environmental stimulus

47
Meditation and Contemplation
  • Setting aside some personal time for meditation
    and contemplation can greatly enhance mental, and
    perhaps even physical,
    health

48
Spirituality
  • A unique characteristic of human existence
  • Should not be overlooked as an effective means
    for some to achieve mental and physical well-being

49
Family, Peer, and Community Connections
  • Belonging to groups can affect a persons
    motivation and performance in very positive ways
  • People tend to associate with others most like
    themselves (e.g., family members,
    coworkers, members of community
    and religious organizations)
  • These groups provide a connection
    with people who share similar values
    and interests

50
Freedom From Prejudice
  • Acceptance of cultural differences
    allows individuals to
  • Learn about other cultures
  • See cultural variations in a
    positive light
  • Affirm the value of these differences

51
Freedom From Prejudice
  • Acceptance of individual differences
  • Recognize existence of differences
  • Listen until you can tell
    the other person's story
  • Work toward
    win-win solution

52
Stress Management
53
Stress
  • Stress is a state of physical or psychological
    arousal.
  • Hazard of emergency work
  • Always present to some degree
  • EMS providers must manage stress
  • to prevent Burnout
  • 3 phases of stress response
  • Alarm reaction
  • Resistance
  • Exhaustion

54
3 Phases of Stress Reaction Phase 1 - Alarm
Reaction
  • Fight or flight phenomenon
  • Considered to be positive takes only seconds to
    become activated
  • Prepares individual for action/self-defense
  • Mediated by the sympathetic nervous system branch
    of the autonomic nervous system

55
Alarm Reaction
  • Fight or flight phenomenon
  • Physiological response
  • Increased heart rate
  • Increased blood pressure
  • Pupillary dilation
  • Excessive perspiration
  • Relaxation of bronchial tree
  • Increased blood glucose levels
  • Slowed digestion
  • Sense of anxiety
  • Alarm reaction ends when body realizes the event
    is no longer dangerous

56
Phase 2 - Resistance
  • The individual begins to adapt to the stress
    through the use of defense mechanisms.
  • Reaction to stressor may change with time.

57
Phase 3 - Exhaustion
  • Prolonged exposure to the same stressors leads to
    the exhaustion of an individuals adaptation
    energy. Signs of the alarm reaction reappear,
    and are more difficult to reverse.
  • Increased susceptibility to physical
  • and psychological ailments
  • Rest and recovery
  • are needed

58
Factors that Trigger the Stress Response
  • Examples include Loss of something that is of
    value Injury or threat of injury Poor health
    or nutrition Frustration Ineffective coping
    skills

59
Causes of Stress in EMS
  • ?Environmental
  • Siren noise
  • Inclement weather
  • Confined work places
  • Rapid scene response
  • Life and death decision making
  • ? Psychosocial
  • family relationships
  • conflicts with supervisors, co-workers
  • abusive patients

60
Causes of Stress in EMS
  • ? Personality
  • Need to be liked
  • Personal expectations
  • Feelings of guilt and anxiety

61
Reactions to Stress
  • Vary with individuals
    and affected by
  • Previous exposure to the stressor
  • Perception of the event
  • Experience
  • Personal coping skills

62
Three Types of Stress Reactions
  • Acute Stress Reaction
  • a reaction that occurs soon after a catastrophic
    event has powerful impact on person
  • Delayed Stress Reaction
  • occurs days, weeks, or months after a critical
    incident also called
  • post-traumatic stress disorder
  • Cumulative Stress Reaction
  • continuous exposure to stressors
  • burnout

63
Delayed Stress Reaction - Post-Traumatic Stress
Disorder
  • Effects
  • marital problems, alcohol drug abuse,
    personality changes, increased suicide incidence
  • Signs and Symptoms
  • Re-experiencing the traumatic event
  • Diminished responsiveness to the external world
  • Interpersonal relationships altered
  • Hyper-alertness
  • Difficulty sleeping
  • Survivor guilt
  • Memory impairment
  • Avoidance of any activities that may cause recall
    of event
  • Avoidance of thoughts or feelings associated with
    the incident

64
Physiological and Psychological Effects of Stress
  • Anxiousness in certain situations
  • or unusual circumstances is
  • normal a warning system for self-protection
    preparation for action
  • Detrimental reactions to anxiety/stress -a
    continued state of alertness beyond the state of
    the emergency self-preparation for danger has
    not been reduced

65
Physical Effects of Anxiety/Stress
  • Heart palpitations
  • Difficult/rapid breathing
  • Chest tightness/pain
  • Anorexia
  • Flushing, diaphoresis
  • Sleep disturbances
  • Aching muscles and joints
  • Backache, headache

66
Emotional Effects of Anxiety/Stress
  • Panic reactions
  • Fear
  • Anger
  • Denial
  • Feeling overwhelmed

67
Cognitive Effects of Anxiety/Stress
  • Difficulty making decisions
  • Disorientation, decreased level of awareness
  • Memory problems, poor
    concentration
  • Distressing dreams

68
Behavioral Effects of Anxiety/Stress
  • Crying spells
  • Hyperactivity
  • Withdrawal
  • Changes in eating
    habits
  • Increased smoking
  • Increased alcohol consumption
  • Drug abuse

69
Adaptation to Stress
  • Dynamic, evolving process whereby one learns
    successful ways to deal with stressful situations
  • This process
  • Usually begins with using defense mechanisms
  • Coping skills then developed
  • Followed by problem solving
  • Culminating in mastery

70
Defense Mechanisms
  • Adaptive function of personality
  • Assists in adjusting to stressful situations
  • Helps in avoiding dealing with problems
  • Defense mechanisms
  • repression - involuntary banishment of
    unacceptable ideas or impulses into the
    unconscious
  • regression - return to an earlier level of
    emotional adjustment
  • projection - attributing to another person those
    thoughts, feelings, motives, or desires which are
    really ones own unacceptable traits

71
Defense Mechanisms continued
  • rationalization - process of ascribing acceptable
    or worthwhile motives to feelings, thoughts, or
    behavior which really have other unrecognized
    motives
  • reaction formation - direction of overt behavior
    or attitudes in precisely the opposite direction
    of the individuals underlying, unacceptable
    impulses
  • denial - unconscious disavowal of thoughts,
    feelings, wishes, or needs which are
  • consciously unacceptable

72
Responding to Stress
  • Coping
  • active, confronting process
  • information gathered/used to change
  • or adjust to a new situation
  • Problem solving
  • healthy approach to everyday concerns
  • uses problem analysis, option analysis for
    action, determination of course of action
  • Mastery
  • ability to see multiple option/potential
    solutions
  • results from experience with similar situations

73
Stress Management Techniques
  • Methods used to initially manage stress include
  • Reframing
  • Controlled breathing
  • Progressive relaxation
  • Guided imagery

74
Stress Management
  • Reframing
  • looking at situation from different point of view
  • Controlled breathing
  • natural stress reliever creates calm
  • Progressive relaxation
  • tighten/relax particular muscle groups fools
    body into thinking it is relaxing
  • Guided imagery
  • guided thru stress response by concentrating on
    an image that helps relieve stress

75
Other Stress Interventions
  • Being aware of personal limitations
  • Peer counseling and group discussions
  • Proper diet, sleep, and rest
  • Pursuit of positive activities outside of EMS to
    balance work and recreation
  • Utilizing other intervention programs that may be
    available through EMS agencies, hospitals, and
    other groups

76
Critical Incident Stress Management
  • CISM is an organized, formal, peer and mental
    health support network and process
  • Enables emergency personnel to vent feelings
  • Facilitates understanding of stressful responses
  • Reassures personnel that what they are
    experiencing is normal and may be common to
    others involved in the incident

77
CISM
  • Situations in which CISM should be considered
  • Line of duty injury or death
  • Disaster
  • Emergency worker suicide
  • Infant/ child death
  • Extreme threat to emergency worker
  • Prolonged incident regardless if end is loss or
    success
  • Victims known to operations personnel
  • Death/ injury of civilian caused by operations
  • Other significant event

78
Components of CISM
  • Pre-incident stress training
  • On-scene support to distressed personnel
  • Individual consults
  • Defusing services immediately after a large scale
    incident
  • Mobilization services after large scale incident
  • Critical incident stress debriefing 24 to 72
    hours after an event
  • Follow-up services
  • Specialty debriefings to non-emergency groups in
    the community
  • Support during routine discussions of an incident
  • Advice to command staff during large scale
    incident
  • 1-800-225-2473

79
Defusing
  • Informal gathering of the people involved in the
    event and two-person CISM-trained teams who are
    also peers
  • Usually takes place within 8 hours after an event
  • Allows initial release of feelings
  • Allows opportunity for people to share their
    experiences
  • Usually lasts lt one hour

80
Debriefing
  • More formal than a defusing
  • Conducted in a confidential setting
  • Usually takes place 24 to72 hours after the event
  • Conducted by a specially trained CISM team of
    other emergency services personnel and mental
    health workers
  • Only those present at the incident
    are allowed to attend a debriefing

81
Reducing Crisis-induced Stress
  • Taking care of the care taker
  • Appropriate rest breaks
  • Replacement of food and fluids
  • Limitation of exposure to incident
  • Change of assignments
  • Providing post-event defusing/ debriefing
  • Studies note that most people will recover
    naturally from stressful situation

82
Death and Dying
  • Elizabeth Kubler-Ross found that most people go
    through 5 stages of grief
  • Denial - no, not me
  • Anger - why me?
  • Bargaining - okay, but first let
  • me...
  • Depression - yes, me in mourning
  • withdraws, retreats
  • Acceptance - okay, Im not afraid family may now
    need more support

83
Conveying News of a Sudden Death
  • Gather family in a private area
  • Advise them of patient's death, with a brief
    description of circumstances causing the death
  • The words death or dead should be used
  • Be compassionate
  • Allow family to see their relative if they
    choose prepare family in laymen terms of what
    they may see

84
Common Needs of the Paramedic when Dealing with
Death and Dying
  • Paramedic may experience some of the stages of
    grief
  • Support from friends, coworkers, family
    following incident
  • Opportunity to process specific incident and
    obtain closure important
  • Use available resources to avoid effects of
    cumulative stress

85
Developmental considerations when dealing with
death and dying
  • Newborn to age three
  • Children will sense that something has happened
    in the family.
  • Children will realize that people are crying and
    are sad all the time.
  • Children will realize that
    there is much activity in
    their household.

86
Developmental considerations when dealing with
death and dying
  • Newborn to age three
  • Watch for changes in
  • Eating or sleeping patterns
  • Irritability
  • Suggestions
  • Be sensitive to the childs needs
  • Try to maintain consistency in routines
  • Maintain consistency with significant people in
    the childs life

87
Developmental considerations when dealing with
death and dying
  • Three to six years of age
  • Child does not have concept of the finality of
    death
  • Believes that the person will return and will
    continually ask when the person will return
  • Believes in magical thinking (feels responsible
    for the death)
  • Child may believe that everyone
  • else they love will also die

88
Developmental considerations when dealing with
death and dying
  • Three to six years of age
  • Watch for changes in
  • Behavior patterns with friends and at school
  • Difficulty sleeping
  • Changes in eating habits
  • Suggestions
  • Emphasize to the child that he was not
    responsible for the death
  • Reinforce that when people are sad they cry
    crying is normal and natural
  • Encourage the child to draw pictures of his
    feelings, or talk about his feelings

89
Developmental considerations when dealing with
death and dying
  • Six to nine years of age
  • Beginning to understand the finality of death
  • Will seek out detailed explanations for the death
  • Will be afraid other significant people in their
    lives will die as well
  • Be uncomfortable in expressing feelings. May act
    silly or embarrassed when talking about death

90
Developmental considerations when dealing with
death and dying
  • Six to nine years of age
  • Suggestions
  • Talk about the normal feelings of anger, sadness
    and guilt
  • Share your own feelings about death do not be
    afraid to cry in front of the child- this gives
    the child permission to express their feelings

91
Developmental considerations when dealing with
death and dying
  • Nine to twelve years of age
  • Aware of the finality of death
  • Concerned with practical matters concerning the
    childs lifestyle
  • May want to know all the details surrounding the
    death
  • May try to act like an adult, but then show
    regression to an earlier stage of emotional
    response

92
Developmental considerations when dealing with
death and dying
  • Nine to twelve years of age
  • Suggestions
  • Set aside time to talk about feelings
  • Encourage sharing of memories to
    facilitate grief response

93
Developmental considerations when dealing with
death and dying
  • Elderly
  • Concerned about other family members
  • Concerned about further loss of independence
  • Concerned about cost

94
Quotes to Think About...
  • Every human being is the author of his own health
    or disease.
  • Author Sivananda
  • No rain - no rainbow.
  • Author unknown

95
Well-Being of the Paramedic
  • Material prepared by
  • Brian Sobeck, BA, NREMT-P (NIEMSCA)
  • Modifications by
  • Sharon Hopkins, RN, BSN,EMT-P
  • Questions ??
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